Hospital checklists work really well -- except when they're not used

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Atul Gawande (previously) made an enormous shift in the practice of medicine with his research on checklists, summarized in his book The Checklist Manifesto; Gawande identified a core paradox with checklists, which is that surgeons hate to use them, finding them reductive and tedious, but overwhelmingly, surgeons would prefer to be operated on by other surgeons who were using a checklist to guide the procedure.

Now, a decade later, the empirical data on checklists is looking pretty dismal. Not because checklists don't work, but because surgical teams ignore them, skipping over checklist items and assuming that they've taken care of them without bothering to check.

A survey of UK surgical staff identified three key reasons that checklists were skipped over: first, peer-pressure, wherein people following the checklist were mocked and exhorted to "shut up and get on with it"; second, "inappropriate or illogical" checklists that had criteria that weren't applicable to the situation; and third, because they were considered time-wasters in a time-constrained environment.

The bad news is that these factors have led to much of checklists' promise being squandered. The good news is that they're pretty easy to fix.

In a 2013 study13, Dixon-Woods found that an African hospital using the WHO surgical checklist had regular shortages of the basic tools — such as surgical markers, antibiotics and pulse oximeters — that are required to complete the list. But the staff often ticked those boxes anyway; as one anaesthetist pointed out, it was often better for a patient to undergo surgery without these supplies than not to have surgery at all. If the checklist is going to succeed in low-income settings, these problems have to be addressed. “There's no point in having an item that says, 'Have the antibiotics been given?' if there are no antibiotics in the hospital,” says Dixon-Woods.

The clear lesson for hospital leaders is that they cannot just dump a stack of checklists in an operating room — they must observe them being used. Are team members all present? Are they rushing, or skipping steps? If so, then the lapses should be discussed and addressed.

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